Acute Migraine Therapy, Chiang Rai 2012

8/2/2019 Acute Migraine Therapy, Chiang Rai 2012

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Beyond the frontier ofacute migraine

therapySurat Tanprawate, MD, MSc(London), FRCP(T)

Division of Neurology, Chiang Mai University

4.4.2012 Chiang Rai

Wednesday, April 4, 2012


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The Headache, George Cruikshank (1819)



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Why we got headache



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Why we got headache

(1)(2)

(3)

(1) primary

(2) secondary

(3) cranial neuralgiaWednesday, April 4, 2012


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Description and Criteria,Migraine, c/w aura

International Classification of

Headache Disorder-II, 2004

1. Primary headache:TTH, migraine, Cluster

2. Secondary headache:Headache attributed to...

3. Cranial neuralgia:e.g., trigeminal neuralgia...



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Leading causes of years of life livedwith a disability (YLDs)

Leonardi M. J Headache Pain (2003) 4:S12S17



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Genetic

Environmental

and factor

Cause Pathophysiology of

acute migrainePathophysiology of

episodic and chronic

migraine

- Genetic

: FHM, TREK

-Trigger factor

Pathophysiology- Aura

- vasodilatation

- neurogenic inflammation

- peripheral and central

sensitization

- Trigemino vascular system

Neurotransmitter

- Serotonergic system

- Dopaminergic system

Clinical: chronic and transform

migraine, allodynia, neck pain

Anatomical: PAG, centralsensitization

episodic

constant

episodic become chronic

acute on chronic

Evolution of MigraineWednesday, April 4, 2012


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Neuroanatomical

Processing of Vascular

Head Pain

CDS: Cortical Spreading DepressionPAG: Periaqueductal gray matterCSD: Cortical spreading depressionNRM: Nucleus raphe magnus

TG: Trigeminal GangliaTNC: Trigeminal Nucleus Caudalis

Geoffrey A. Headache2008

- substance P

- Neurokinin A

- CGRP

- serotonin

- glutamate

- prostaglandins

- inflammatory cytokines

Peripheral sensitization



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When headache

progress-what happen

Central sensitization

of Trigeminal nucleus

caudalis(TNC)

Periaqueductal grey

matter dysfunction

FEATUREs

- neck pain

- allodynia

- less features oftypical migraine

- less throbbing

- less N/V

- more tension

like headache



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How to treat migraine

effectively?

Dated 1583

Circa 300 AD

From papyrus, 2500 BCWednesday, April 4, 2012


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Comprehensive treatment plan

Education, reassurance and lifestyle modification

Avoiding triggers to prevent attack Non-phamacologic treatment

Treating the acute attack

Long-term preventive therapy Physical and alternative medicine

Silberstein SD. Wolffs headache. 2008



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Episodic

Migraine

Frequent

migraine attack

Life stylemodification Acute migrainetreatment

+ Prophylaxismedication

Treatment fail

Migraine with

co-morbidity

Inadequate

treatment

Migraine with

MOH

- Life stylemodification?- Right drug,

dose, duration?

- Psychiatriccondition- Sleep

condition

Suc

cessfultre

atment

True refractory

migraine

use acute

medication >

15days/months,

> 3 months

failed > 3

preventive

medication group



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Comprehensive treatment plan

Education, reassurance and lifestyle modification

Avoiding triggers to prevent attack Non-phamacologic treatment

Treating the acute attack

Long-term preventive therapy Physical and alternative medicine

Silberstein SD. Wolffs headache. 2008



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What do you prescribewhen they got headache?



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Pharmacotherapy of

acute migraine attack

Non-specific

Acetaminophen,

NSAIDs

caffeine

opioids

neuroleptic

Specific

Dihydroergotamine

Ergotamine

Triptan



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NSAIDs



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Evers, S et al. European Journalof Neurology 2009, 16: 968981

Non-specific

migraine

medication:

Analgesics withevidence of efficacyEFNS migraine

treatment guideline2009



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Options

Fixed combination ASA + Paracetamol+ caffeine more effective than single

substance

selective COX-2 inhibitors Valdecoxib 20-40 mg

Celecoxib 400 mg

Rofecoxib 25-50 mg



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Ergotamine



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Ergot

The word ergot is derived from argot,

old French for cock spur

The ergot of RyeCock spur

400 BC: ergotism was reported- vasospasm- gangrene

- abortion

Fungus Claviceps purpurea

1862: ergot use totreat migraine



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Specific

Medication These agents have a strong structural

similarity to neurotransmitters,

norepilephrine, dopamine(D2),serotonin(5-HT1A, 1B, 1C, 1D, 1F, 2A, 2C, 3, 4)

5-HT1B: constricts the pain-producingintracranial, extracranial blood vessel

in the meninges

5-HT1D: presynaptically inhibitstrigeminal peptide release andinterfere with central trigeminal

nucleus caudalis

DHE injection form

Ergotamine tartrate+ Caffeine

Ergot &

Dihydroergotamine



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Contraindication of ergot

use... coronary, cerebral and peripheral vascular disease

pregnancy

renal or hepatic failure

uncontrolled hypertension

sepsis

hypersensitivity reaction

hemiplegic and basilar type migraine

migraine with prolong aura



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Triptans

5-HT 1B/1D receptor agonists seven different formulations

options for route of delivery

oral tablets or melts

nasal spray

subcutaneous injection taken as soon as possible

* i.e. as soon as the patient knows that this is a migraine

* if there is aura, take at the start of the headache phase

Less side effect than

ergotamine



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Possible Sites of Action of Triptans in the

Trigeminovascular System



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Sumatriptan

Eletriptan

Zolmitriptan

Triptan available in

Thai market



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Evers, S et al. European Journal of Neurology 2009, 16: 968981

Triptans

(Imigran)

(Zomig)

(Relpax)

Sumatriptan 2.5

Zolmitriptan

Eletriptan3.31.0-2.0

Time to peak plasma(h)



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Opioids

IM 100 mg tramadol = IM 75 mgdiclofenac (80% response rate)

Pethidine; Morphine: highly addictive



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Parenteral acute treatment of migraine for

use in clinic or emergency department

Medication Dose Route

DHE Up to 1 mg sc, im, iv

Sumatriptan 4, 6 mg sc

Metoclopamide 10 mg iv

Chlorpromazine 25-50 mg iv

Ketorolac 30 mg iv im, iv

Dexamethasone 4-10 mg im, iv

Valproic acid 500-1000 mg iv

Magnesium 1 g iv

Tepper SJ, Spears RC. Neurol Clin 2009;417-427



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HOW TO

useDRUGS?

-content...

whats drug

whats route

early vs late treatment

how to evaluate

what need to be concernWednesday, April 4, 2012


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Choice and route of

therapy

severity and frequency of attack

associated symptoms coexistent disorders

previous treatment response

drugs efficacy

potential for overuse

adverse events



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Strategies in acute

migraine attack

Step care

Strategic care

treatment is escalated after first-line medication fail

initial treatment is based on measurement of the

severity of illness or other factors



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Second series of attack

Step-care

Stratified care

Migrainediagnosis

First-line Rx

(simple analgesic)

Second-line Rx

(combination

therapy)

Third-line Rx

(specific anti-

migraineous)

First series of attack Third series of attack

Migrainediagnosis

Assessment of

illness severity

Impact questionnaire High need

Moderate

need

Low need

Stratification

Step vs Stratified care



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The Disability in Strategies of Care(DISC study)

RCT trail: step vs strategic care

Participant: 835 adults

Result: Strategic care provides significantlybetter outcomes than step care strategies

within or across attacks as measured by

headache response and disability time(52.7% vs 40.6% vs 36.4%, p< 0.001)

Lipton RB, Stewart WF et al. JAMA 2000;284:2599-2605



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Stratified care and

migraine assessmentFactors need to be considered

Frequency Severity

The present and level of disability

Associated non-headache symptoms

US Headache Consortium Guideline 2007



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MIDAS and HIT-6



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Scale used in Chiang MaiHeadache Clinic


C it i f i i i


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Criteria for assessing migraine

patient severity

Mild to moderate migraine Moderate to severe migraine

Headache are almost mild-to-

moderate intensity

Non-headache associatedsymptoms, if present are not severe

in intensity

The impact of the headache on the

patients lifestyle is not significant:MIDAS Gr. 1 or 2, HIT Gr. I or 2

Non-triptan

Headache that frequently develop

to moderate or severe in intensity

Significant non-headacheassociated symptoms, which may

be severe in intensity

The impact of the headache on the

patients lifestyle is significant:MIDAS Gr. III or IV (moderate or

severe impact)

Triptan or DHE

Curr Med Res Opin2002.Wednesday, April 4, 2012


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Early intervention preventsescalation and can increase

the effectiveness of the

treatment

Cady RK, Clin Therap 2000; 22: 103548.

Ferrari MD,Eur Neurol 2005;53(Suppl 1):17-21

Should we advise patients to treat

migraine attacks early ?



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Pain free after 2 hours

Improvement of headache from moderate or

severe to mild or none after 2 hours

Consistent efficacy in two of three attacks

No Headache recurrence and no further drug

intake within 24 hours successful treatment

(so-called sustained pain relief or pain free)

Successful treatment of

migraine attack



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When the drug is

ineffectiveat least two attacks should be treated

inadequate response

change the dose

change the route

add adjuvant therapy

change medication

SD Silberstein Lancet 2004; 363: 38191



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Occipital nerve

block technique

Location

Occipital protuberance-

Mastoid process

23-gauge needle

Bupivacaine orLidocaine 2-4 cc



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What need to be

concerned ?Medication Overuse Headache

(MOH)

Migraine co-morbidities

Long term medication side effect


Diagnosis: Medication Overuse Headache


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Diagnosis: Medication Overuse Headache

Paemeleleire K et al. Acta neurol. belg., 2006, 106, 43-51

Sun-Edelstein C et al. Cephalalgia, 2008, 29, 445452Classification using ICHD-IIR


A man with chronic A CM woman with addict


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A man with chronic

migraine got addict to

medication, diazepam,

xanax, diazepam

A CM woman with addict

to tramadol, cafergot, and

pethidine iv


E ti


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Ergotism: Limb ischemia



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A 42 Thai woman

with ergotamine

overuse (15 tab/day)



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..

Ravichankra, India

.

.

.

..



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Thank

Youfor

Your

KindAttent

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www.t

haiheada

chesoc

iety.c

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Facebo

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Acute Migraine Therapy, Chiang Rai 2012

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